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TOBACCO
MODULE D
CONTENTS
TABLES i
PREFACE ii
TOBACCO USE 1
REFERENCES 7
TABLES 9
TABLES
D1 Number of Cigarettes Smoked Per Day Past 30 Days D2 Ever Smoked Daily D3 Smoked 100 Cigarettes Lifetime D4 Current Cigar Smoking Past 30 Days D5 Ever Smoke to Control Weight D6 Likelihood of Smoking in the Next Year D7 Agreement with Eight Statements About Smoking D8 Estimated Prevalence of Adult Cigarette Smoking at Least Once a Month D9 Sources for Obtaining Cigarettes D10 Current Desire to Quit Smoking Cigarettes D11 Lifetime Frequency of Smoking Cessation Attempts D12 Type of Help Sought at School to Help Quit Smoking Past 12 Months D13 Tobacco Education in School Past 12 Months D14 Refusal Skills Training in School Past 12 Months D15 Perceived Ability to Refuse Friends Offer of Cigarettes
CHKS Report 2008-09 i Tobacco Module D
PREFACE
This report provides the detailed results from the districtrsquos administration of the California Healthy Kids Survey (CHKS) supplementary Tobacco Module D It is designed to be used in conjunction with the findings on tobacco from the main report on CHKS Core Module A The report is divided into two sections (a) a discussion of the items by topic and (b) the results for each item presented by grade in tables In both sections users are provided references to questionnaire items by number as well as the actual item wording An index at the beginning of the tables refers users from survey item numbers and variables to the table number in which the results are provided The index also provides references to the relevant Core tables
Users should also consult CDErsquos new Getting Results volume (Part II) California Action Guide to Tobacco Use Prevention Education It provides research-based strategies for program implementation
ACKNOWLEDGEMENTS The CHKS was developed under contract from the California Department of Education (CDE) by WestEd in collaboration with Duerr Evaluation Resources Assisting in its development were an Advisory Committee consisting of researchers education practitioners from county offices of education school districts and schools across the state and representatives from federal and state agencies involved in assessing youth health-related behaviors Professor Rod Skager served as a special consultant For more information about the survey call the toll-free Helpline at 8888417536 or visit the CHKS website at wwwwestedorghks
Special thanks are due to Dr Jennifer Unger (Institute for Health Promotion and Disease Prevention Research University of Southern California) who helped in the preparation of individual sections of this report particularly in examining how data might be used At WestEd Drs Barbara Dietsch and William McCarthy were the lead writers of this section
Gregory Austin PhD Tom Herman Administrator CHKS Director Safe and Healthy Kids Program Office WestEd California Department of Education Los Alamitos CA Sacramento CA
CHKS Report 2008-09 ii Tobacco Module D
TOBACCO USE
SMOKING FREQUENCY AND PATTERNS
REGULAR SMOKING AND NUMBER OF CIGARETTES SMOKED PER DAY Question D1 Have you ever smoked cigarettes daily that is at least one cigarette every day for 30 days Question D3 During the past 30 days on the days you smoked how many cigarettes did you smoke per day Question D4 Have you smoked 100 cigarettes in your life
Table D1 provides the number of cigarettes students smoked per day on the days they smoked in the past 30 days These data give an indication of how much cigarette users consume on the days that they choose to smoke
Table D2 reports the proportion of respondents who ever smoked daily defined as at least one cigarette every day for 30 days Comparing these results with the proportion of current regular smokers in Table A43 provides an indication of the proportion of smokers who may have succeeded in stopping smoking or at least reducing use from a daily habit
Table D3 reports the proportion of respondents who smoked 100 cigarettes in their life This item is an indication of established smoking amongst youth1
CIGARS Question D6 During the past 30 days on how many days did you smoke any cigars cigarillos or little cigars
Table D4 reports the rate of any current (past 30 days) smoking of cigars cigarillos or little cigars Cigars recently have become popular among young adults and teenagers2 In the mid- to late-1990s cigar bars and lounges began to appear and several prominent actors were photographed smoking cigars Cigar smoking appeared to be trendy and associated with wealth and enjoyment of life Many people believe that cigars are less dangerous than cigarettes they think that the tobacco in cigars is more pure or natural and they believe that cigar smokers inhale less than cigarette smokers do However studies have shown that cigar smoking is associated with an increased risk of cancer just like cigarette smoking3
SMOKING TO CONTROL WEIGHT Question D2 Did you ever smoke to control your weight
Why youth say they smoke is important to know when developing intervention programs The proportion of students reporting that they ever smoked to control their weight is found in Table D5 Weight control is an important issue for young females in particular Information about smoking and weight control should be included in prevention and cessation classes The social influences model encourages students to discuss the reasons they smoke or why they think their peers smoke Table D7 further provides the percent of students who believe smoking helps control weight
CHKS Report 2008-09 1 Tobacco Module D
ATTITUDES AND OPINIONS
INTENTIONS TO SMOKE Question D15 How likely do you think it is that you will smoke one or more cigarettes in the next year
Table D6 provides the proportion of respondents who indicated a likelihood that they might smoke within the next year In determining program needs it is important to take into consideration not only the proportion of students who report that they smoke but also the proportion who indicate future intent to smoke This is one of the most powerful predictors of smoking4 Students who acknowledge any possibility of future intent to smoke should be considered at increased risk of smoking compared to those who say ldquoI am sure it wonrsquot happenrdquo If students have not made a firm commitment not to smoke in the future encourage them to do so and to make their commitment formal by putting it in writing or stating it in front of their classmates
REASONS TO USENOT USE Questions D17-24 Please indicate whether or not you agree with the following statements Smoking makes kids look grown uphellipSmoking makes your teeth yellowhellipSmoking is coolhellipSmoking makes you smell badhellipSmoking helps you make friendshellipSmoking is bad for your healthhellipSmoking helps you relaxhellipSmoking helps control your weight
Respondents were given eight statements about smoking and asked to indicate how much they agreed or disagreed with each Table D7 provides the proportion of students who reported that they agreed or very much agreed with each statement The statements include both positive reasons for use (eg ldquoSmoking is coolrdquo) and adverse effects that might deter use (ldquoSmoking makes your teeth yellowrdquo) These are reasons why teens say they smoke and consequences that are typically discussed in smoking prevention programs As such this item is useful in helping assess the effectiveness of tobacco curriculum on youth attitudes The adverse consequences that seem to be the most powerful in influencing nonsmoking are those most immediately relevant to youth such as those that affect appearance and social relationships rather than those related to long-term health5
The proportion of youth that agreed that smoking is bad for health or dangerous can be compared with the proportion that perceived smoking as harmful in Table A46 in the main report
PEER AND ADULT NORMS
PEER ATTITUDES AND BEHAVIOR Adolescents tend to overestimate the actual prevalence of smoking among their peers For example in the 1996 Independent Evaluation of the California Tobacco Control Prevention and Education Program only 17 of the 8th graders reported smoking in the past month but the 8th graders estimated that 43 of their peers smoked Similarly only 27 of the 10th-grade students reported smoking in the past month whereas 10th graders estimated that 51 of their 10th-grade peers smoked6
Because of the overestimation of peer substance use students may smoke in an effort to imitate these peers when in reality most of the peers are not smokers Therefore prevention programs focusing on normative expectations designed to counter these misperceptions have been found to be an effective prevention strategy78 If local youth are significantly overestimating peer smoking behavior use the CHKS results to counter this You can monitor the effectiveness of this strategy by follow-up administrations of the survey to determine if student estimates of peer smoking become more realistic
CHKS Report 2008-09 2 Tobacco Module D
over time as would be expected Theoretically this should be accompanied by a reduction in overall smoking rates
ADULT SMOKING Question D16 About how many adults you know smoke cigarettes
In Table D8 youth estimates of the proportion of adults they know who smoke at least once a month are presented (none some many most or all) Adult behavior provides a model for youth The results for this item can be used in parent education efforts to demonstrate how studentsrsquo perception of adult use might influence their decisions to use or not to use (If the supplementary Module C was also administered these findings can be compared with their estimates of adult use of marijuana)
ACCESS TO CIGARETTES
Question D5 If you smoked cigarettes during the past 30 days how did you usually get them
The Core module asks students to identify how easy it is to obtain cigarettes (see Table A47) To shed further light on cigarette availability Table D9 provides data on where students obtain cigarettes
Recent laws have attempted to make it more difficult for underage youth to obtain cigarettes Store employees are instructed to ask people for proof of age when they attempt to purchase cigarettes Many stores keep their cigarette displays locked so adolescents cannot steal cigarettes Cigarette vending machines have been removed from many places where adolescents could access them However these policies are effective only if enforced9 It is important to determine whether these policies have indeed made it more difficult for adolescents to obtain cigarettes from retail sources
What percent of students reported purchasing cigarettes from retail sources and were not asked to show proof of age The 2001 YRBS reported that 19 of the high school students who had smoked in the past month had purchased cigarettes at a store or gas station in the past month Among the underage students who had purchased cigarettes at a store or gas station 67 reported that they were not asked to show proof of age10 If students are getting cigarettes from retail sources policies restricting youth access are not being enforced
What percent of students reported stealing cigarettes from people or stores What percent of students reported getting their cigarettes from friends or family members If they are getting cigarettes from social sources older relatives and friends may need to be educated about the importance of not giving cigarettes to minors Now that it is more difficult for adolescents to obtain cigarettes from retail sources some researchers have speculated that they may rely more heavily on social sources (friends and relatives) or illegal channels to obtain their cigarettes
CHKS Report 2008-09 3 Tobacco Module D
SMOKING CESSATION
Question D7 If you now smoke cigarettes would you like to quit smoking Question D8 How many times have you tried to quit smoking cigarettes Question D9-11 If you used tobacco during the past 12 months did you do any of the following things at school to get help to quit using hellipgo to a special group or class helliptalk to an adult at your school about how to quit helliptalk to a peer helper about how to quit
The CHKS asks youth five cessation-related questions whether they desired to quit the frequency of cessation attempts and whether they ever sought help to quit at the school from an adult or peer helper or from a special group or class Providing encouragement and support for youth cessation efforts is extremely important because the process of quitting smoking is extremely difficult11 People who try to quit smoking often have intense negative physical and psychological reactions that make them extremely likely to relapse They typically attempt to quit smoking several times before they quit successfully12 In this process they typically progress through stages of change of which five have been identified
bull not wanting to quit
bull contemplating it
bull taking action
bull a risk relapse stage and
bull finally a maintenance stage in which the smoker has abstained from smoking for a long period of time such as six months and has a high probability of success
This Transtheoretical Model of Change (TMC) also referred to as the Stages of Change Theory maintains that the way to help people quit smoking is to develop programs that address the participantrsquos readiness to change Unlike some stage models it recognizes that subjects can move back and forth between stages or recycle several times through the stages Unfortunately a major controlled scientific trial failed to support the utility of the Stages of Change Theory for increasing effectiveness of tobacco control efforts targeted to British school children13 However that is not to say that programs using this approach should not be included in your districtrsquos cessation efforts
Table D10 provides the proportion of students who have a desire to quit If only a few smokers express a desire to quit then efforts may need to be focused on demonstrating why they should stop If a large proportion wish to quit it may be a good idea to establish a school-based smoking cessation clinic or class or at least a referral process for referral to a community-based program This is particularly important if a high proportion indicate a desire to quit but relatively few have ever tried as indicated in Table D11 Students may be more likely to quit successfully if they have support from other students who wish to quit school staff and trained health educators
Table D11 reports the frequency that smokers have attempted to quit smoking The CSS has shown consistently that just under half of the 9th- and 11th-grade smokers (40 and 48 respectively) try to stop the habit at least once This is a higher cessation-attempt rate than found for illicit drugs and over twice as high as found for alcohol
Table D12 reports the proportion of students who ever went to a special group or class at school or who ever talked with an adult or peer helper at school about quitting If these services are available but students are not using them greater outreach efforts are clearly needed Consideration should be given to assessing the adequacy of the school TUPE program in promoting the benefits of quitting This is particularly important if students express a high desire to quit andor frequency of quit attempts
CHKS Report 2008-09 4 Tobacco Module D
PREVENTION PROGRAM EXPOSURE
Module D has been designed especially with the needs of TUPE program development in mind Table D7 reports student agreement with eight statements about smoking and its effects that are typically covered by prevention curricula Tables D13 through D15 below help assess exposure to any tobacco lessons and to refusal skills training one of the most common tobacco education strategies
EXPOSURE TO ANY LESSONS Question D13 During the past 12 months did you do any of these things at school helliphave lessons about tobacco and its effects on the body
The CHKS asks respondents about whether they had any lessons in school about tobacco and its effects on the body in the past year The results are reported in Table D13 If a high proportion report ldquoyesrdquo you might compare the curriculum content with the strategies assessed by other items in the surveymdash such as adverse consequences refusal skills and normative educationmdashto determine how well the intended messages have been learned If a high proportion of students say ldquonordquo or ldquodonrsquot knowrdquo the adequacy of current prevention efforts needs to be examined
REFUSAL SKILLS TRAINING (SELF-EFFICACY) Question D12 How hard would it be for you to refuse or say ldquonordquo to a friend who offered you a cigarette to smoke Question D14 During the past 12 months did you do any of these things at school hellippractice different ways to refuse or say ldquonordquo to tobacco offers
In Tables D14 and D15 students report on whether they had any practice saying ldquonordquo to tobacco offers in the past year and on their ability to refuse a friendrsquos offer of a cigarette to smoke Confidence in onersquos ability to perform an action successfully is called self-efficacy People tend to perform the actions that they think they can perform well and they tend to avoid actions that they think they are unable to perform14 Some students are not confident that they could successfully resist a cigarette offer from a peer they may not even try to say ldquonordquo
It is not easy for students to tell their friends that they do not want to engage in behavior that their friends think is acceptable15 Prevention research has shown that it is not enough to just tell youth to ldquojust say nordquo Self-efficacy develops through successful performance of the behavior They need to engage in role-playing and practice These skills must be reinforced with regular booster sessions and practiced each year until students feel confident in their ability to refuse tobacco Students who have practiced saying ldquonordquo and have been successful will have increased confidence and be more likely to say ldquonordquo in the future
Most tobacco prevention curricula that have shown effectiveness incorporate refusal skills training16
Typically students do role-plays in which one student offers a cigarette and another student practices saying ldquonordquo If the student says ldquonordquo assertively and firmly compliment the student If the student seems uncertain brainstorm ways that the student can say ldquonordquo more assertively without being bullied ridiculed or pressured into trying the cigarette Of course students will say ldquonordquo to a cigarette offer only if they truly do not want to smoke Therefore it is not enough to teach students how to say ldquonordquo Students must be convinced that smoking is not attractive or cool
If respondents report that they havenrsquot received any resistance training in the past year or students have had training but report little confidence in refusal skills the value of current anti-tobacco curricula needs to be assessed17 Even if the curriculum being used does have regular refusal skills training the teachers may not be implementing the program appropriately18
CHKS Report 2008-09 5 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
CONTENTS
TABLES i
PREFACE ii
TOBACCO USE 1
REFERENCES 7
TABLES 9
TABLES
D1 Number of Cigarettes Smoked Per Day Past 30 Days D2 Ever Smoked Daily D3 Smoked 100 Cigarettes Lifetime D4 Current Cigar Smoking Past 30 Days D5 Ever Smoke to Control Weight D6 Likelihood of Smoking in the Next Year D7 Agreement with Eight Statements About Smoking D8 Estimated Prevalence of Adult Cigarette Smoking at Least Once a Month D9 Sources for Obtaining Cigarettes D10 Current Desire to Quit Smoking Cigarettes D11 Lifetime Frequency of Smoking Cessation Attempts D12 Type of Help Sought at School to Help Quit Smoking Past 12 Months D13 Tobacco Education in School Past 12 Months D14 Refusal Skills Training in School Past 12 Months D15 Perceived Ability to Refuse Friends Offer of Cigarettes
CHKS Report 2008-09 i Tobacco Module D
PREFACE
This report provides the detailed results from the districtrsquos administration of the California Healthy Kids Survey (CHKS) supplementary Tobacco Module D It is designed to be used in conjunction with the findings on tobacco from the main report on CHKS Core Module A The report is divided into two sections (a) a discussion of the items by topic and (b) the results for each item presented by grade in tables In both sections users are provided references to questionnaire items by number as well as the actual item wording An index at the beginning of the tables refers users from survey item numbers and variables to the table number in which the results are provided The index also provides references to the relevant Core tables
Users should also consult CDErsquos new Getting Results volume (Part II) California Action Guide to Tobacco Use Prevention Education It provides research-based strategies for program implementation
ACKNOWLEDGEMENTS The CHKS was developed under contract from the California Department of Education (CDE) by WestEd in collaboration with Duerr Evaluation Resources Assisting in its development were an Advisory Committee consisting of researchers education practitioners from county offices of education school districts and schools across the state and representatives from federal and state agencies involved in assessing youth health-related behaviors Professor Rod Skager served as a special consultant For more information about the survey call the toll-free Helpline at 8888417536 or visit the CHKS website at wwwwestedorghks
Special thanks are due to Dr Jennifer Unger (Institute for Health Promotion and Disease Prevention Research University of Southern California) who helped in the preparation of individual sections of this report particularly in examining how data might be used At WestEd Drs Barbara Dietsch and William McCarthy were the lead writers of this section
Gregory Austin PhD Tom Herman Administrator CHKS Director Safe and Healthy Kids Program Office WestEd California Department of Education Los Alamitos CA Sacramento CA
CHKS Report 2008-09 ii Tobacco Module D
TOBACCO USE
SMOKING FREQUENCY AND PATTERNS
REGULAR SMOKING AND NUMBER OF CIGARETTES SMOKED PER DAY Question D1 Have you ever smoked cigarettes daily that is at least one cigarette every day for 30 days Question D3 During the past 30 days on the days you smoked how many cigarettes did you smoke per day Question D4 Have you smoked 100 cigarettes in your life
Table D1 provides the number of cigarettes students smoked per day on the days they smoked in the past 30 days These data give an indication of how much cigarette users consume on the days that they choose to smoke
Table D2 reports the proportion of respondents who ever smoked daily defined as at least one cigarette every day for 30 days Comparing these results with the proportion of current regular smokers in Table A43 provides an indication of the proportion of smokers who may have succeeded in stopping smoking or at least reducing use from a daily habit
Table D3 reports the proportion of respondents who smoked 100 cigarettes in their life This item is an indication of established smoking amongst youth1
CIGARS Question D6 During the past 30 days on how many days did you smoke any cigars cigarillos or little cigars
Table D4 reports the rate of any current (past 30 days) smoking of cigars cigarillos or little cigars Cigars recently have become popular among young adults and teenagers2 In the mid- to late-1990s cigar bars and lounges began to appear and several prominent actors were photographed smoking cigars Cigar smoking appeared to be trendy and associated with wealth and enjoyment of life Many people believe that cigars are less dangerous than cigarettes they think that the tobacco in cigars is more pure or natural and they believe that cigar smokers inhale less than cigarette smokers do However studies have shown that cigar smoking is associated with an increased risk of cancer just like cigarette smoking3
SMOKING TO CONTROL WEIGHT Question D2 Did you ever smoke to control your weight
Why youth say they smoke is important to know when developing intervention programs The proportion of students reporting that they ever smoked to control their weight is found in Table D5 Weight control is an important issue for young females in particular Information about smoking and weight control should be included in prevention and cessation classes The social influences model encourages students to discuss the reasons they smoke or why they think their peers smoke Table D7 further provides the percent of students who believe smoking helps control weight
CHKS Report 2008-09 1 Tobacco Module D
ATTITUDES AND OPINIONS
INTENTIONS TO SMOKE Question D15 How likely do you think it is that you will smoke one or more cigarettes in the next year
Table D6 provides the proportion of respondents who indicated a likelihood that they might smoke within the next year In determining program needs it is important to take into consideration not only the proportion of students who report that they smoke but also the proportion who indicate future intent to smoke This is one of the most powerful predictors of smoking4 Students who acknowledge any possibility of future intent to smoke should be considered at increased risk of smoking compared to those who say ldquoI am sure it wonrsquot happenrdquo If students have not made a firm commitment not to smoke in the future encourage them to do so and to make their commitment formal by putting it in writing or stating it in front of their classmates
REASONS TO USENOT USE Questions D17-24 Please indicate whether or not you agree with the following statements Smoking makes kids look grown uphellipSmoking makes your teeth yellowhellipSmoking is coolhellipSmoking makes you smell badhellipSmoking helps you make friendshellipSmoking is bad for your healthhellipSmoking helps you relaxhellipSmoking helps control your weight
Respondents were given eight statements about smoking and asked to indicate how much they agreed or disagreed with each Table D7 provides the proportion of students who reported that they agreed or very much agreed with each statement The statements include both positive reasons for use (eg ldquoSmoking is coolrdquo) and adverse effects that might deter use (ldquoSmoking makes your teeth yellowrdquo) These are reasons why teens say they smoke and consequences that are typically discussed in smoking prevention programs As such this item is useful in helping assess the effectiveness of tobacco curriculum on youth attitudes The adverse consequences that seem to be the most powerful in influencing nonsmoking are those most immediately relevant to youth such as those that affect appearance and social relationships rather than those related to long-term health5
The proportion of youth that agreed that smoking is bad for health or dangerous can be compared with the proportion that perceived smoking as harmful in Table A46 in the main report
PEER AND ADULT NORMS
PEER ATTITUDES AND BEHAVIOR Adolescents tend to overestimate the actual prevalence of smoking among their peers For example in the 1996 Independent Evaluation of the California Tobacco Control Prevention and Education Program only 17 of the 8th graders reported smoking in the past month but the 8th graders estimated that 43 of their peers smoked Similarly only 27 of the 10th-grade students reported smoking in the past month whereas 10th graders estimated that 51 of their 10th-grade peers smoked6
Because of the overestimation of peer substance use students may smoke in an effort to imitate these peers when in reality most of the peers are not smokers Therefore prevention programs focusing on normative expectations designed to counter these misperceptions have been found to be an effective prevention strategy78 If local youth are significantly overestimating peer smoking behavior use the CHKS results to counter this You can monitor the effectiveness of this strategy by follow-up administrations of the survey to determine if student estimates of peer smoking become more realistic
CHKS Report 2008-09 2 Tobacco Module D
over time as would be expected Theoretically this should be accompanied by a reduction in overall smoking rates
ADULT SMOKING Question D16 About how many adults you know smoke cigarettes
In Table D8 youth estimates of the proportion of adults they know who smoke at least once a month are presented (none some many most or all) Adult behavior provides a model for youth The results for this item can be used in parent education efforts to demonstrate how studentsrsquo perception of adult use might influence their decisions to use or not to use (If the supplementary Module C was also administered these findings can be compared with their estimates of adult use of marijuana)
ACCESS TO CIGARETTES
Question D5 If you smoked cigarettes during the past 30 days how did you usually get them
The Core module asks students to identify how easy it is to obtain cigarettes (see Table A47) To shed further light on cigarette availability Table D9 provides data on where students obtain cigarettes
Recent laws have attempted to make it more difficult for underage youth to obtain cigarettes Store employees are instructed to ask people for proof of age when they attempt to purchase cigarettes Many stores keep their cigarette displays locked so adolescents cannot steal cigarettes Cigarette vending machines have been removed from many places where adolescents could access them However these policies are effective only if enforced9 It is important to determine whether these policies have indeed made it more difficult for adolescents to obtain cigarettes from retail sources
What percent of students reported purchasing cigarettes from retail sources and were not asked to show proof of age The 2001 YRBS reported that 19 of the high school students who had smoked in the past month had purchased cigarettes at a store or gas station in the past month Among the underage students who had purchased cigarettes at a store or gas station 67 reported that they were not asked to show proof of age10 If students are getting cigarettes from retail sources policies restricting youth access are not being enforced
What percent of students reported stealing cigarettes from people or stores What percent of students reported getting their cigarettes from friends or family members If they are getting cigarettes from social sources older relatives and friends may need to be educated about the importance of not giving cigarettes to minors Now that it is more difficult for adolescents to obtain cigarettes from retail sources some researchers have speculated that they may rely more heavily on social sources (friends and relatives) or illegal channels to obtain their cigarettes
CHKS Report 2008-09 3 Tobacco Module D
SMOKING CESSATION
Question D7 If you now smoke cigarettes would you like to quit smoking Question D8 How many times have you tried to quit smoking cigarettes Question D9-11 If you used tobacco during the past 12 months did you do any of the following things at school to get help to quit using hellipgo to a special group or class helliptalk to an adult at your school about how to quit helliptalk to a peer helper about how to quit
The CHKS asks youth five cessation-related questions whether they desired to quit the frequency of cessation attempts and whether they ever sought help to quit at the school from an adult or peer helper or from a special group or class Providing encouragement and support for youth cessation efforts is extremely important because the process of quitting smoking is extremely difficult11 People who try to quit smoking often have intense negative physical and psychological reactions that make them extremely likely to relapse They typically attempt to quit smoking several times before they quit successfully12 In this process they typically progress through stages of change of which five have been identified
bull not wanting to quit
bull contemplating it
bull taking action
bull a risk relapse stage and
bull finally a maintenance stage in which the smoker has abstained from smoking for a long period of time such as six months and has a high probability of success
This Transtheoretical Model of Change (TMC) also referred to as the Stages of Change Theory maintains that the way to help people quit smoking is to develop programs that address the participantrsquos readiness to change Unlike some stage models it recognizes that subjects can move back and forth between stages or recycle several times through the stages Unfortunately a major controlled scientific trial failed to support the utility of the Stages of Change Theory for increasing effectiveness of tobacco control efforts targeted to British school children13 However that is not to say that programs using this approach should not be included in your districtrsquos cessation efforts
Table D10 provides the proportion of students who have a desire to quit If only a few smokers express a desire to quit then efforts may need to be focused on demonstrating why they should stop If a large proportion wish to quit it may be a good idea to establish a school-based smoking cessation clinic or class or at least a referral process for referral to a community-based program This is particularly important if a high proportion indicate a desire to quit but relatively few have ever tried as indicated in Table D11 Students may be more likely to quit successfully if they have support from other students who wish to quit school staff and trained health educators
Table D11 reports the frequency that smokers have attempted to quit smoking The CSS has shown consistently that just under half of the 9th- and 11th-grade smokers (40 and 48 respectively) try to stop the habit at least once This is a higher cessation-attempt rate than found for illicit drugs and over twice as high as found for alcohol
Table D12 reports the proportion of students who ever went to a special group or class at school or who ever talked with an adult or peer helper at school about quitting If these services are available but students are not using them greater outreach efforts are clearly needed Consideration should be given to assessing the adequacy of the school TUPE program in promoting the benefits of quitting This is particularly important if students express a high desire to quit andor frequency of quit attempts
CHKS Report 2008-09 4 Tobacco Module D
PREVENTION PROGRAM EXPOSURE
Module D has been designed especially with the needs of TUPE program development in mind Table D7 reports student agreement with eight statements about smoking and its effects that are typically covered by prevention curricula Tables D13 through D15 below help assess exposure to any tobacco lessons and to refusal skills training one of the most common tobacco education strategies
EXPOSURE TO ANY LESSONS Question D13 During the past 12 months did you do any of these things at school helliphave lessons about tobacco and its effects on the body
The CHKS asks respondents about whether they had any lessons in school about tobacco and its effects on the body in the past year The results are reported in Table D13 If a high proportion report ldquoyesrdquo you might compare the curriculum content with the strategies assessed by other items in the surveymdash such as adverse consequences refusal skills and normative educationmdashto determine how well the intended messages have been learned If a high proportion of students say ldquonordquo or ldquodonrsquot knowrdquo the adequacy of current prevention efforts needs to be examined
REFUSAL SKILLS TRAINING (SELF-EFFICACY) Question D12 How hard would it be for you to refuse or say ldquonordquo to a friend who offered you a cigarette to smoke Question D14 During the past 12 months did you do any of these things at school hellippractice different ways to refuse or say ldquonordquo to tobacco offers
In Tables D14 and D15 students report on whether they had any practice saying ldquonordquo to tobacco offers in the past year and on their ability to refuse a friendrsquos offer of a cigarette to smoke Confidence in onersquos ability to perform an action successfully is called self-efficacy People tend to perform the actions that they think they can perform well and they tend to avoid actions that they think they are unable to perform14 Some students are not confident that they could successfully resist a cigarette offer from a peer they may not even try to say ldquonordquo
It is not easy for students to tell their friends that they do not want to engage in behavior that their friends think is acceptable15 Prevention research has shown that it is not enough to just tell youth to ldquojust say nordquo Self-efficacy develops through successful performance of the behavior They need to engage in role-playing and practice These skills must be reinforced with regular booster sessions and practiced each year until students feel confident in their ability to refuse tobacco Students who have practiced saying ldquonordquo and have been successful will have increased confidence and be more likely to say ldquonordquo in the future
Most tobacco prevention curricula that have shown effectiveness incorporate refusal skills training16
Typically students do role-plays in which one student offers a cigarette and another student practices saying ldquonordquo If the student says ldquonordquo assertively and firmly compliment the student If the student seems uncertain brainstorm ways that the student can say ldquonordquo more assertively without being bullied ridiculed or pressured into trying the cigarette Of course students will say ldquonordquo to a cigarette offer only if they truly do not want to smoke Therefore it is not enough to teach students how to say ldquonordquo Students must be convinced that smoking is not attractive or cool
If respondents report that they havenrsquot received any resistance training in the past year or students have had training but report little confidence in refusal skills the value of current anti-tobacco curricula needs to be assessed17 Even if the curriculum being used does have regular refusal skills training the teachers may not be implementing the program appropriately18
CHKS Report 2008-09 5 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
PREFACE
This report provides the detailed results from the districtrsquos administration of the California Healthy Kids Survey (CHKS) supplementary Tobacco Module D It is designed to be used in conjunction with the findings on tobacco from the main report on CHKS Core Module A The report is divided into two sections (a) a discussion of the items by topic and (b) the results for each item presented by grade in tables In both sections users are provided references to questionnaire items by number as well as the actual item wording An index at the beginning of the tables refers users from survey item numbers and variables to the table number in which the results are provided The index also provides references to the relevant Core tables
Users should also consult CDErsquos new Getting Results volume (Part II) California Action Guide to Tobacco Use Prevention Education It provides research-based strategies for program implementation
ACKNOWLEDGEMENTS The CHKS was developed under contract from the California Department of Education (CDE) by WestEd in collaboration with Duerr Evaluation Resources Assisting in its development were an Advisory Committee consisting of researchers education practitioners from county offices of education school districts and schools across the state and representatives from federal and state agencies involved in assessing youth health-related behaviors Professor Rod Skager served as a special consultant For more information about the survey call the toll-free Helpline at 8888417536 or visit the CHKS website at wwwwestedorghks
Special thanks are due to Dr Jennifer Unger (Institute for Health Promotion and Disease Prevention Research University of Southern California) who helped in the preparation of individual sections of this report particularly in examining how data might be used At WestEd Drs Barbara Dietsch and William McCarthy were the lead writers of this section
Gregory Austin PhD Tom Herman Administrator CHKS Director Safe and Healthy Kids Program Office WestEd California Department of Education Los Alamitos CA Sacramento CA
CHKS Report 2008-09 ii Tobacco Module D
TOBACCO USE
SMOKING FREQUENCY AND PATTERNS
REGULAR SMOKING AND NUMBER OF CIGARETTES SMOKED PER DAY Question D1 Have you ever smoked cigarettes daily that is at least one cigarette every day for 30 days Question D3 During the past 30 days on the days you smoked how many cigarettes did you smoke per day Question D4 Have you smoked 100 cigarettes in your life
Table D1 provides the number of cigarettes students smoked per day on the days they smoked in the past 30 days These data give an indication of how much cigarette users consume on the days that they choose to smoke
Table D2 reports the proportion of respondents who ever smoked daily defined as at least one cigarette every day for 30 days Comparing these results with the proportion of current regular smokers in Table A43 provides an indication of the proportion of smokers who may have succeeded in stopping smoking or at least reducing use from a daily habit
Table D3 reports the proportion of respondents who smoked 100 cigarettes in their life This item is an indication of established smoking amongst youth1
CIGARS Question D6 During the past 30 days on how many days did you smoke any cigars cigarillos or little cigars
Table D4 reports the rate of any current (past 30 days) smoking of cigars cigarillos or little cigars Cigars recently have become popular among young adults and teenagers2 In the mid- to late-1990s cigar bars and lounges began to appear and several prominent actors were photographed smoking cigars Cigar smoking appeared to be trendy and associated with wealth and enjoyment of life Many people believe that cigars are less dangerous than cigarettes they think that the tobacco in cigars is more pure or natural and they believe that cigar smokers inhale less than cigarette smokers do However studies have shown that cigar smoking is associated with an increased risk of cancer just like cigarette smoking3
SMOKING TO CONTROL WEIGHT Question D2 Did you ever smoke to control your weight
Why youth say they smoke is important to know when developing intervention programs The proportion of students reporting that they ever smoked to control their weight is found in Table D5 Weight control is an important issue for young females in particular Information about smoking and weight control should be included in prevention and cessation classes The social influences model encourages students to discuss the reasons they smoke or why they think their peers smoke Table D7 further provides the percent of students who believe smoking helps control weight
CHKS Report 2008-09 1 Tobacco Module D
ATTITUDES AND OPINIONS
INTENTIONS TO SMOKE Question D15 How likely do you think it is that you will smoke one or more cigarettes in the next year
Table D6 provides the proportion of respondents who indicated a likelihood that they might smoke within the next year In determining program needs it is important to take into consideration not only the proportion of students who report that they smoke but also the proportion who indicate future intent to smoke This is one of the most powerful predictors of smoking4 Students who acknowledge any possibility of future intent to smoke should be considered at increased risk of smoking compared to those who say ldquoI am sure it wonrsquot happenrdquo If students have not made a firm commitment not to smoke in the future encourage them to do so and to make their commitment formal by putting it in writing or stating it in front of their classmates
REASONS TO USENOT USE Questions D17-24 Please indicate whether or not you agree with the following statements Smoking makes kids look grown uphellipSmoking makes your teeth yellowhellipSmoking is coolhellipSmoking makes you smell badhellipSmoking helps you make friendshellipSmoking is bad for your healthhellipSmoking helps you relaxhellipSmoking helps control your weight
Respondents were given eight statements about smoking and asked to indicate how much they agreed or disagreed with each Table D7 provides the proportion of students who reported that they agreed or very much agreed with each statement The statements include both positive reasons for use (eg ldquoSmoking is coolrdquo) and adverse effects that might deter use (ldquoSmoking makes your teeth yellowrdquo) These are reasons why teens say they smoke and consequences that are typically discussed in smoking prevention programs As such this item is useful in helping assess the effectiveness of tobacco curriculum on youth attitudes The adverse consequences that seem to be the most powerful in influencing nonsmoking are those most immediately relevant to youth such as those that affect appearance and social relationships rather than those related to long-term health5
The proportion of youth that agreed that smoking is bad for health or dangerous can be compared with the proportion that perceived smoking as harmful in Table A46 in the main report
PEER AND ADULT NORMS
PEER ATTITUDES AND BEHAVIOR Adolescents tend to overestimate the actual prevalence of smoking among their peers For example in the 1996 Independent Evaluation of the California Tobacco Control Prevention and Education Program only 17 of the 8th graders reported smoking in the past month but the 8th graders estimated that 43 of their peers smoked Similarly only 27 of the 10th-grade students reported smoking in the past month whereas 10th graders estimated that 51 of their 10th-grade peers smoked6
Because of the overestimation of peer substance use students may smoke in an effort to imitate these peers when in reality most of the peers are not smokers Therefore prevention programs focusing on normative expectations designed to counter these misperceptions have been found to be an effective prevention strategy78 If local youth are significantly overestimating peer smoking behavior use the CHKS results to counter this You can monitor the effectiveness of this strategy by follow-up administrations of the survey to determine if student estimates of peer smoking become more realistic
CHKS Report 2008-09 2 Tobacco Module D
over time as would be expected Theoretically this should be accompanied by a reduction in overall smoking rates
ADULT SMOKING Question D16 About how many adults you know smoke cigarettes
In Table D8 youth estimates of the proportion of adults they know who smoke at least once a month are presented (none some many most or all) Adult behavior provides a model for youth The results for this item can be used in parent education efforts to demonstrate how studentsrsquo perception of adult use might influence their decisions to use or not to use (If the supplementary Module C was also administered these findings can be compared with their estimates of adult use of marijuana)
ACCESS TO CIGARETTES
Question D5 If you smoked cigarettes during the past 30 days how did you usually get them
The Core module asks students to identify how easy it is to obtain cigarettes (see Table A47) To shed further light on cigarette availability Table D9 provides data on where students obtain cigarettes
Recent laws have attempted to make it more difficult for underage youth to obtain cigarettes Store employees are instructed to ask people for proof of age when they attempt to purchase cigarettes Many stores keep their cigarette displays locked so adolescents cannot steal cigarettes Cigarette vending machines have been removed from many places where adolescents could access them However these policies are effective only if enforced9 It is important to determine whether these policies have indeed made it more difficult for adolescents to obtain cigarettes from retail sources
What percent of students reported purchasing cigarettes from retail sources and were not asked to show proof of age The 2001 YRBS reported that 19 of the high school students who had smoked in the past month had purchased cigarettes at a store or gas station in the past month Among the underage students who had purchased cigarettes at a store or gas station 67 reported that they were not asked to show proof of age10 If students are getting cigarettes from retail sources policies restricting youth access are not being enforced
What percent of students reported stealing cigarettes from people or stores What percent of students reported getting their cigarettes from friends or family members If they are getting cigarettes from social sources older relatives and friends may need to be educated about the importance of not giving cigarettes to minors Now that it is more difficult for adolescents to obtain cigarettes from retail sources some researchers have speculated that they may rely more heavily on social sources (friends and relatives) or illegal channels to obtain their cigarettes
CHKS Report 2008-09 3 Tobacco Module D
SMOKING CESSATION
Question D7 If you now smoke cigarettes would you like to quit smoking Question D8 How many times have you tried to quit smoking cigarettes Question D9-11 If you used tobacco during the past 12 months did you do any of the following things at school to get help to quit using hellipgo to a special group or class helliptalk to an adult at your school about how to quit helliptalk to a peer helper about how to quit
The CHKS asks youth five cessation-related questions whether they desired to quit the frequency of cessation attempts and whether they ever sought help to quit at the school from an adult or peer helper or from a special group or class Providing encouragement and support for youth cessation efforts is extremely important because the process of quitting smoking is extremely difficult11 People who try to quit smoking often have intense negative physical and psychological reactions that make them extremely likely to relapse They typically attempt to quit smoking several times before they quit successfully12 In this process they typically progress through stages of change of which five have been identified
bull not wanting to quit
bull contemplating it
bull taking action
bull a risk relapse stage and
bull finally a maintenance stage in which the smoker has abstained from smoking for a long period of time such as six months and has a high probability of success
This Transtheoretical Model of Change (TMC) also referred to as the Stages of Change Theory maintains that the way to help people quit smoking is to develop programs that address the participantrsquos readiness to change Unlike some stage models it recognizes that subjects can move back and forth between stages or recycle several times through the stages Unfortunately a major controlled scientific trial failed to support the utility of the Stages of Change Theory for increasing effectiveness of tobacco control efforts targeted to British school children13 However that is not to say that programs using this approach should not be included in your districtrsquos cessation efforts
Table D10 provides the proportion of students who have a desire to quit If only a few smokers express a desire to quit then efforts may need to be focused on demonstrating why they should stop If a large proportion wish to quit it may be a good idea to establish a school-based smoking cessation clinic or class or at least a referral process for referral to a community-based program This is particularly important if a high proportion indicate a desire to quit but relatively few have ever tried as indicated in Table D11 Students may be more likely to quit successfully if they have support from other students who wish to quit school staff and trained health educators
Table D11 reports the frequency that smokers have attempted to quit smoking The CSS has shown consistently that just under half of the 9th- and 11th-grade smokers (40 and 48 respectively) try to stop the habit at least once This is a higher cessation-attempt rate than found for illicit drugs and over twice as high as found for alcohol
Table D12 reports the proportion of students who ever went to a special group or class at school or who ever talked with an adult or peer helper at school about quitting If these services are available but students are not using them greater outreach efforts are clearly needed Consideration should be given to assessing the adequacy of the school TUPE program in promoting the benefits of quitting This is particularly important if students express a high desire to quit andor frequency of quit attempts
CHKS Report 2008-09 4 Tobacco Module D
PREVENTION PROGRAM EXPOSURE
Module D has been designed especially with the needs of TUPE program development in mind Table D7 reports student agreement with eight statements about smoking and its effects that are typically covered by prevention curricula Tables D13 through D15 below help assess exposure to any tobacco lessons and to refusal skills training one of the most common tobacco education strategies
EXPOSURE TO ANY LESSONS Question D13 During the past 12 months did you do any of these things at school helliphave lessons about tobacco and its effects on the body
The CHKS asks respondents about whether they had any lessons in school about tobacco and its effects on the body in the past year The results are reported in Table D13 If a high proportion report ldquoyesrdquo you might compare the curriculum content with the strategies assessed by other items in the surveymdash such as adverse consequences refusal skills and normative educationmdashto determine how well the intended messages have been learned If a high proportion of students say ldquonordquo or ldquodonrsquot knowrdquo the adequacy of current prevention efforts needs to be examined
REFUSAL SKILLS TRAINING (SELF-EFFICACY) Question D12 How hard would it be for you to refuse or say ldquonordquo to a friend who offered you a cigarette to smoke Question D14 During the past 12 months did you do any of these things at school hellippractice different ways to refuse or say ldquonordquo to tobacco offers
In Tables D14 and D15 students report on whether they had any practice saying ldquonordquo to tobacco offers in the past year and on their ability to refuse a friendrsquos offer of a cigarette to smoke Confidence in onersquos ability to perform an action successfully is called self-efficacy People tend to perform the actions that they think they can perform well and they tend to avoid actions that they think they are unable to perform14 Some students are not confident that they could successfully resist a cigarette offer from a peer they may not even try to say ldquonordquo
It is not easy for students to tell their friends that they do not want to engage in behavior that their friends think is acceptable15 Prevention research has shown that it is not enough to just tell youth to ldquojust say nordquo Self-efficacy develops through successful performance of the behavior They need to engage in role-playing and practice These skills must be reinforced with regular booster sessions and practiced each year until students feel confident in their ability to refuse tobacco Students who have practiced saying ldquonordquo and have been successful will have increased confidence and be more likely to say ldquonordquo in the future
Most tobacco prevention curricula that have shown effectiveness incorporate refusal skills training16
Typically students do role-plays in which one student offers a cigarette and another student practices saying ldquonordquo If the student says ldquonordquo assertively and firmly compliment the student If the student seems uncertain brainstorm ways that the student can say ldquonordquo more assertively without being bullied ridiculed or pressured into trying the cigarette Of course students will say ldquonordquo to a cigarette offer only if they truly do not want to smoke Therefore it is not enough to teach students how to say ldquonordquo Students must be convinced that smoking is not attractive or cool
If respondents report that they havenrsquot received any resistance training in the past year or students have had training but report little confidence in refusal skills the value of current anti-tobacco curricula needs to be assessed17 Even if the curriculum being used does have regular refusal skills training the teachers may not be implementing the program appropriately18
CHKS Report 2008-09 5 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
TOBACCO USE
SMOKING FREQUENCY AND PATTERNS
REGULAR SMOKING AND NUMBER OF CIGARETTES SMOKED PER DAY Question D1 Have you ever smoked cigarettes daily that is at least one cigarette every day for 30 days Question D3 During the past 30 days on the days you smoked how many cigarettes did you smoke per day Question D4 Have you smoked 100 cigarettes in your life
Table D1 provides the number of cigarettes students smoked per day on the days they smoked in the past 30 days These data give an indication of how much cigarette users consume on the days that they choose to smoke
Table D2 reports the proportion of respondents who ever smoked daily defined as at least one cigarette every day for 30 days Comparing these results with the proportion of current regular smokers in Table A43 provides an indication of the proportion of smokers who may have succeeded in stopping smoking or at least reducing use from a daily habit
Table D3 reports the proportion of respondents who smoked 100 cigarettes in their life This item is an indication of established smoking amongst youth1
CIGARS Question D6 During the past 30 days on how many days did you smoke any cigars cigarillos or little cigars
Table D4 reports the rate of any current (past 30 days) smoking of cigars cigarillos or little cigars Cigars recently have become popular among young adults and teenagers2 In the mid- to late-1990s cigar bars and lounges began to appear and several prominent actors were photographed smoking cigars Cigar smoking appeared to be trendy and associated with wealth and enjoyment of life Many people believe that cigars are less dangerous than cigarettes they think that the tobacco in cigars is more pure or natural and they believe that cigar smokers inhale less than cigarette smokers do However studies have shown that cigar smoking is associated with an increased risk of cancer just like cigarette smoking3
SMOKING TO CONTROL WEIGHT Question D2 Did you ever smoke to control your weight
Why youth say they smoke is important to know when developing intervention programs The proportion of students reporting that they ever smoked to control their weight is found in Table D5 Weight control is an important issue for young females in particular Information about smoking and weight control should be included in prevention and cessation classes The social influences model encourages students to discuss the reasons they smoke or why they think their peers smoke Table D7 further provides the percent of students who believe smoking helps control weight
CHKS Report 2008-09 1 Tobacco Module D
ATTITUDES AND OPINIONS
INTENTIONS TO SMOKE Question D15 How likely do you think it is that you will smoke one or more cigarettes in the next year
Table D6 provides the proportion of respondents who indicated a likelihood that they might smoke within the next year In determining program needs it is important to take into consideration not only the proportion of students who report that they smoke but also the proportion who indicate future intent to smoke This is one of the most powerful predictors of smoking4 Students who acknowledge any possibility of future intent to smoke should be considered at increased risk of smoking compared to those who say ldquoI am sure it wonrsquot happenrdquo If students have not made a firm commitment not to smoke in the future encourage them to do so and to make their commitment formal by putting it in writing or stating it in front of their classmates
REASONS TO USENOT USE Questions D17-24 Please indicate whether or not you agree with the following statements Smoking makes kids look grown uphellipSmoking makes your teeth yellowhellipSmoking is coolhellipSmoking makes you smell badhellipSmoking helps you make friendshellipSmoking is bad for your healthhellipSmoking helps you relaxhellipSmoking helps control your weight
Respondents were given eight statements about smoking and asked to indicate how much they agreed or disagreed with each Table D7 provides the proportion of students who reported that they agreed or very much agreed with each statement The statements include both positive reasons for use (eg ldquoSmoking is coolrdquo) and adverse effects that might deter use (ldquoSmoking makes your teeth yellowrdquo) These are reasons why teens say they smoke and consequences that are typically discussed in smoking prevention programs As such this item is useful in helping assess the effectiveness of tobacco curriculum on youth attitudes The adverse consequences that seem to be the most powerful in influencing nonsmoking are those most immediately relevant to youth such as those that affect appearance and social relationships rather than those related to long-term health5
The proportion of youth that agreed that smoking is bad for health or dangerous can be compared with the proportion that perceived smoking as harmful in Table A46 in the main report
PEER AND ADULT NORMS
PEER ATTITUDES AND BEHAVIOR Adolescents tend to overestimate the actual prevalence of smoking among their peers For example in the 1996 Independent Evaluation of the California Tobacco Control Prevention and Education Program only 17 of the 8th graders reported smoking in the past month but the 8th graders estimated that 43 of their peers smoked Similarly only 27 of the 10th-grade students reported smoking in the past month whereas 10th graders estimated that 51 of their 10th-grade peers smoked6
Because of the overestimation of peer substance use students may smoke in an effort to imitate these peers when in reality most of the peers are not smokers Therefore prevention programs focusing on normative expectations designed to counter these misperceptions have been found to be an effective prevention strategy78 If local youth are significantly overestimating peer smoking behavior use the CHKS results to counter this You can monitor the effectiveness of this strategy by follow-up administrations of the survey to determine if student estimates of peer smoking become more realistic
CHKS Report 2008-09 2 Tobacco Module D
over time as would be expected Theoretically this should be accompanied by a reduction in overall smoking rates
ADULT SMOKING Question D16 About how many adults you know smoke cigarettes
In Table D8 youth estimates of the proportion of adults they know who smoke at least once a month are presented (none some many most or all) Adult behavior provides a model for youth The results for this item can be used in parent education efforts to demonstrate how studentsrsquo perception of adult use might influence their decisions to use or not to use (If the supplementary Module C was also administered these findings can be compared with their estimates of adult use of marijuana)
ACCESS TO CIGARETTES
Question D5 If you smoked cigarettes during the past 30 days how did you usually get them
The Core module asks students to identify how easy it is to obtain cigarettes (see Table A47) To shed further light on cigarette availability Table D9 provides data on where students obtain cigarettes
Recent laws have attempted to make it more difficult for underage youth to obtain cigarettes Store employees are instructed to ask people for proof of age when they attempt to purchase cigarettes Many stores keep their cigarette displays locked so adolescents cannot steal cigarettes Cigarette vending machines have been removed from many places where adolescents could access them However these policies are effective only if enforced9 It is important to determine whether these policies have indeed made it more difficult for adolescents to obtain cigarettes from retail sources
What percent of students reported purchasing cigarettes from retail sources and were not asked to show proof of age The 2001 YRBS reported that 19 of the high school students who had smoked in the past month had purchased cigarettes at a store or gas station in the past month Among the underage students who had purchased cigarettes at a store or gas station 67 reported that they were not asked to show proof of age10 If students are getting cigarettes from retail sources policies restricting youth access are not being enforced
What percent of students reported stealing cigarettes from people or stores What percent of students reported getting their cigarettes from friends or family members If they are getting cigarettes from social sources older relatives and friends may need to be educated about the importance of not giving cigarettes to minors Now that it is more difficult for adolescents to obtain cigarettes from retail sources some researchers have speculated that they may rely more heavily on social sources (friends and relatives) or illegal channels to obtain their cigarettes
CHKS Report 2008-09 3 Tobacco Module D
SMOKING CESSATION
Question D7 If you now smoke cigarettes would you like to quit smoking Question D8 How many times have you tried to quit smoking cigarettes Question D9-11 If you used tobacco during the past 12 months did you do any of the following things at school to get help to quit using hellipgo to a special group or class helliptalk to an adult at your school about how to quit helliptalk to a peer helper about how to quit
The CHKS asks youth five cessation-related questions whether they desired to quit the frequency of cessation attempts and whether they ever sought help to quit at the school from an adult or peer helper or from a special group or class Providing encouragement and support for youth cessation efforts is extremely important because the process of quitting smoking is extremely difficult11 People who try to quit smoking often have intense negative physical and psychological reactions that make them extremely likely to relapse They typically attempt to quit smoking several times before they quit successfully12 In this process they typically progress through stages of change of which five have been identified
bull not wanting to quit
bull contemplating it
bull taking action
bull a risk relapse stage and
bull finally a maintenance stage in which the smoker has abstained from smoking for a long period of time such as six months and has a high probability of success
This Transtheoretical Model of Change (TMC) also referred to as the Stages of Change Theory maintains that the way to help people quit smoking is to develop programs that address the participantrsquos readiness to change Unlike some stage models it recognizes that subjects can move back and forth between stages or recycle several times through the stages Unfortunately a major controlled scientific trial failed to support the utility of the Stages of Change Theory for increasing effectiveness of tobacco control efforts targeted to British school children13 However that is not to say that programs using this approach should not be included in your districtrsquos cessation efforts
Table D10 provides the proportion of students who have a desire to quit If only a few smokers express a desire to quit then efforts may need to be focused on demonstrating why they should stop If a large proportion wish to quit it may be a good idea to establish a school-based smoking cessation clinic or class or at least a referral process for referral to a community-based program This is particularly important if a high proportion indicate a desire to quit but relatively few have ever tried as indicated in Table D11 Students may be more likely to quit successfully if they have support from other students who wish to quit school staff and trained health educators
Table D11 reports the frequency that smokers have attempted to quit smoking The CSS has shown consistently that just under half of the 9th- and 11th-grade smokers (40 and 48 respectively) try to stop the habit at least once This is a higher cessation-attempt rate than found for illicit drugs and over twice as high as found for alcohol
Table D12 reports the proportion of students who ever went to a special group or class at school or who ever talked with an adult or peer helper at school about quitting If these services are available but students are not using them greater outreach efforts are clearly needed Consideration should be given to assessing the adequacy of the school TUPE program in promoting the benefits of quitting This is particularly important if students express a high desire to quit andor frequency of quit attempts
CHKS Report 2008-09 4 Tobacco Module D
PREVENTION PROGRAM EXPOSURE
Module D has been designed especially with the needs of TUPE program development in mind Table D7 reports student agreement with eight statements about smoking and its effects that are typically covered by prevention curricula Tables D13 through D15 below help assess exposure to any tobacco lessons and to refusal skills training one of the most common tobacco education strategies
EXPOSURE TO ANY LESSONS Question D13 During the past 12 months did you do any of these things at school helliphave lessons about tobacco and its effects on the body
The CHKS asks respondents about whether they had any lessons in school about tobacco and its effects on the body in the past year The results are reported in Table D13 If a high proportion report ldquoyesrdquo you might compare the curriculum content with the strategies assessed by other items in the surveymdash such as adverse consequences refusal skills and normative educationmdashto determine how well the intended messages have been learned If a high proportion of students say ldquonordquo or ldquodonrsquot knowrdquo the adequacy of current prevention efforts needs to be examined
REFUSAL SKILLS TRAINING (SELF-EFFICACY) Question D12 How hard would it be for you to refuse or say ldquonordquo to a friend who offered you a cigarette to smoke Question D14 During the past 12 months did you do any of these things at school hellippractice different ways to refuse or say ldquonordquo to tobacco offers
In Tables D14 and D15 students report on whether they had any practice saying ldquonordquo to tobacco offers in the past year and on their ability to refuse a friendrsquos offer of a cigarette to smoke Confidence in onersquos ability to perform an action successfully is called self-efficacy People tend to perform the actions that they think they can perform well and they tend to avoid actions that they think they are unable to perform14 Some students are not confident that they could successfully resist a cigarette offer from a peer they may not even try to say ldquonordquo
It is not easy for students to tell their friends that they do not want to engage in behavior that their friends think is acceptable15 Prevention research has shown that it is not enough to just tell youth to ldquojust say nordquo Self-efficacy develops through successful performance of the behavior They need to engage in role-playing and practice These skills must be reinforced with regular booster sessions and practiced each year until students feel confident in their ability to refuse tobacco Students who have practiced saying ldquonordquo and have been successful will have increased confidence and be more likely to say ldquonordquo in the future
Most tobacco prevention curricula that have shown effectiveness incorporate refusal skills training16
Typically students do role-plays in which one student offers a cigarette and another student practices saying ldquonordquo If the student says ldquonordquo assertively and firmly compliment the student If the student seems uncertain brainstorm ways that the student can say ldquonordquo more assertively without being bullied ridiculed or pressured into trying the cigarette Of course students will say ldquonordquo to a cigarette offer only if they truly do not want to smoke Therefore it is not enough to teach students how to say ldquonordquo Students must be convinced that smoking is not attractive or cool
If respondents report that they havenrsquot received any resistance training in the past year or students have had training but report little confidence in refusal skills the value of current anti-tobacco curricula needs to be assessed17 Even if the curriculum being used does have regular refusal skills training the teachers may not be implementing the program appropriately18
CHKS Report 2008-09 5 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
ATTITUDES AND OPINIONS
INTENTIONS TO SMOKE Question D15 How likely do you think it is that you will smoke one or more cigarettes in the next year
Table D6 provides the proportion of respondents who indicated a likelihood that they might smoke within the next year In determining program needs it is important to take into consideration not only the proportion of students who report that they smoke but also the proportion who indicate future intent to smoke This is one of the most powerful predictors of smoking4 Students who acknowledge any possibility of future intent to smoke should be considered at increased risk of smoking compared to those who say ldquoI am sure it wonrsquot happenrdquo If students have not made a firm commitment not to smoke in the future encourage them to do so and to make their commitment formal by putting it in writing or stating it in front of their classmates
REASONS TO USENOT USE Questions D17-24 Please indicate whether or not you agree with the following statements Smoking makes kids look grown uphellipSmoking makes your teeth yellowhellipSmoking is coolhellipSmoking makes you smell badhellipSmoking helps you make friendshellipSmoking is bad for your healthhellipSmoking helps you relaxhellipSmoking helps control your weight
Respondents were given eight statements about smoking and asked to indicate how much they agreed or disagreed with each Table D7 provides the proportion of students who reported that they agreed or very much agreed with each statement The statements include both positive reasons for use (eg ldquoSmoking is coolrdquo) and adverse effects that might deter use (ldquoSmoking makes your teeth yellowrdquo) These are reasons why teens say they smoke and consequences that are typically discussed in smoking prevention programs As such this item is useful in helping assess the effectiveness of tobacco curriculum on youth attitudes The adverse consequences that seem to be the most powerful in influencing nonsmoking are those most immediately relevant to youth such as those that affect appearance and social relationships rather than those related to long-term health5
The proportion of youth that agreed that smoking is bad for health or dangerous can be compared with the proportion that perceived smoking as harmful in Table A46 in the main report
PEER AND ADULT NORMS
PEER ATTITUDES AND BEHAVIOR Adolescents tend to overestimate the actual prevalence of smoking among their peers For example in the 1996 Independent Evaluation of the California Tobacco Control Prevention and Education Program only 17 of the 8th graders reported smoking in the past month but the 8th graders estimated that 43 of their peers smoked Similarly only 27 of the 10th-grade students reported smoking in the past month whereas 10th graders estimated that 51 of their 10th-grade peers smoked6
Because of the overestimation of peer substance use students may smoke in an effort to imitate these peers when in reality most of the peers are not smokers Therefore prevention programs focusing on normative expectations designed to counter these misperceptions have been found to be an effective prevention strategy78 If local youth are significantly overestimating peer smoking behavior use the CHKS results to counter this You can monitor the effectiveness of this strategy by follow-up administrations of the survey to determine if student estimates of peer smoking become more realistic
CHKS Report 2008-09 2 Tobacco Module D
over time as would be expected Theoretically this should be accompanied by a reduction in overall smoking rates
ADULT SMOKING Question D16 About how many adults you know smoke cigarettes
In Table D8 youth estimates of the proportion of adults they know who smoke at least once a month are presented (none some many most or all) Adult behavior provides a model for youth The results for this item can be used in parent education efforts to demonstrate how studentsrsquo perception of adult use might influence their decisions to use or not to use (If the supplementary Module C was also administered these findings can be compared with their estimates of adult use of marijuana)
ACCESS TO CIGARETTES
Question D5 If you smoked cigarettes during the past 30 days how did you usually get them
The Core module asks students to identify how easy it is to obtain cigarettes (see Table A47) To shed further light on cigarette availability Table D9 provides data on where students obtain cigarettes
Recent laws have attempted to make it more difficult for underage youth to obtain cigarettes Store employees are instructed to ask people for proof of age when they attempt to purchase cigarettes Many stores keep their cigarette displays locked so adolescents cannot steal cigarettes Cigarette vending machines have been removed from many places where adolescents could access them However these policies are effective only if enforced9 It is important to determine whether these policies have indeed made it more difficult for adolescents to obtain cigarettes from retail sources
What percent of students reported purchasing cigarettes from retail sources and were not asked to show proof of age The 2001 YRBS reported that 19 of the high school students who had smoked in the past month had purchased cigarettes at a store or gas station in the past month Among the underage students who had purchased cigarettes at a store or gas station 67 reported that they were not asked to show proof of age10 If students are getting cigarettes from retail sources policies restricting youth access are not being enforced
What percent of students reported stealing cigarettes from people or stores What percent of students reported getting their cigarettes from friends or family members If they are getting cigarettes from social sources older relatives and friends may need to be educated about the importance of not giving cigarettes to minors Now that it is more difficult for adolescents to obtain cigarettes from retail sources some researchers have speculated that they may rely more heavily on social sources (friends and relatives) or illegal channels to obtain their cigarettes
CHKS Report 2008-09 3 Tobacco Module D
SMOKING CESSATION
Question D7 If you now smoke cigarettes would you like to quit smoking Question D8 How many times have you tried to quit smoking cigarettes Question D9-11 If you used tobacco during the past 12 months did you do any of the following things at school to get help to quit using hellipgo to a special group or class helliptalk to an adult at your school about how to quit helliptalk to a peer helper about how to quit
The CHKS asks youth five cessation-related questions whether they desired to quit the frequency of cessation attempts and whether they ever sought help to quit at the school from an adult or peer helper or from a special group or class Providing encouragement and support for youth cessation efforts is extremely important because the process of quitting smoking is extremely difficult11 People who try to quit smoking often have intense negative physical and psychological reactions that make them extremely likely to relapse They typically attempt to quit smoking several times before they quit successfully12 In this process they typically progress through stages of change of which five have been identified
bull not wanting to quit
bull contemplating it
bull taking action
bull a risk relapse stage and
bull finally a maintenance stage in which the smoker has abstained from smoking for a long period of time such as six months and has a high probability of success
This Transtheoretical Model of Change (TMC) also referred to as the Stages of Change Theory maintains that the way to help people quit smoking is to develop programs that address the participantrsquos readiness to change Unlike some stage models it recognizes that subjects can move back and forth between stages or recycle several times through the stages Unfortunately a major controlled scientific trial failed to support the utility of the Stages of Change Theory for increasing effectiveness of tobacco control efforts targeted to British school children13 However that is not to say that programs using this approach should not be included in your districtrsquos cessation efforts
Table D10 provides the proportion of students who have a desire to quit If only a few smokers express a desire to quit then efforts may need to be focused on demonstrating why they should stop If a large proportion wish to quit it may be a good idea to establish a school-based smoking cessation clinic or class or at least a referral process for referral to a community-based program This is particularly important if a high proportion indicate a desire to quit but relatively few have ever tried as indicated in Table D11 Students may be more likely to quit successfully if they have support from other students who wish to quit school staff and trained health educators
Table D11 reports the frequency that smokers have attempted to quit smoking The CSS has shown consistently that just under half of the 9th- and 11th-grade smokers (40 and 48 respectively) try to stop the habit at least once This is a higher cessation-attempt rate than found for illicit drugs and over twice as high as found for alcohol
Table D12 reports the proportion of students who ever went to a special group or class at school or who ever talked with an adult or peer helper at school about quitting If these services are available but students are not using them greater outreach efforts are clearly needed Consideration should be given to assessing the adequacy of the school TUPE program in promoting the benefits of quitting This is particularly important if students express a high desire to quit andor frequency of quit attempts
CHKS Report 2008-09 4 Tobacco Module D
PREVENTION PROGRAM EXPOSURE
Module D has been designed especially with the needs of TUPE program development in mind Table D7 reports student agreement with eight statements about smoking and its effects that are typically covered by prevention curricula Tables D13 through D15 below help assess exposure to any tobacco lessons and to refusal skills training one of the most common tobacco education strategies
EXPOSURE TO ANY LESSONS Question D13 During the past 12 months did you do any of these things at school helliphave lessons about tobacco and its effects on the body
The CHKS asks respondents about whether they had any lessons in school about tobacco and its effects on the body in the past year The results are reported in Table D13 If a high proportion report ldquoyesrdquo you might compare the curriculum content with the strategies assessed by other items in the surveymdash such as adverse consequences refusal skills and normative educationmdashto determine how well the intended messages have been learned If a high proportion of students say ldquonordquo or ldquodonrsquot knowrdquo the adequacy of current prevention efforts needs to be examined
REFUSAL SKILLS TRAINING (SELF-EFFICACY) Question D12 How hard would it be for you to refuse or say ldquonordquo to a friend who offered you a cigarette to smoke Question D14 During the past 12 months did you do any of these things at school hellippractice different ways to refuse or say ldquonordquo to tobacco offers
In Tables D14 and D15 students report on whether they had any practice saying ldquonordquo to tobacco offers in the past year and on their ability to refuse a friendrsquos offer of a cigarette to smoke Confidence in onersquos ability to perform an action successfully is called self-efficacy People tend to perform the actions that they think they can perform well and they tend to avoid actions that they think they are unable to perform14 Some students are not confident that they could successfully resist a cigarette offer from a peer they may not even try to say ldquonordquo
It is not easy for students to tell their friends that they do not want to engage in behavior that their friends think is acceptable15 Prevention research has shown that it is not enough to just tell youth to ldquojust say nordquo Self-efficacy develops through successful performance of the behavior They need to engage in role-playing and practice These skills must be reinforced with regular booster sessions and practiced each year until students feel confident in their ability to refuse tobacco Students who have practiced saying ldquonordquo and have been successful will have increased confidence and be more likely to say ldquonordquo in the future
Most tobacco prevention curricula that have shown effectiveness incorporate refusal skills training16
Typically students do role-plays in which one student offers a cigarette and another student practices saying ldquonordquo If the student says ldquonordquo assertively and firmly compliment the student If the student seems uncertain brainstorm ways that the student can say ldquonordquo more assertively without being bullied ridiculed or pressured into trying the cigarette Of course students will say ldquonordquo to a cigarette offer only if they truly do not want to smoke Therefore it is not enough to teach students how to say ldquonordquo Students must be convinced that smoking is not attractive or cool
If respondents report that they havenrsquot received any resistance training in the past year or students have had training but report little confidence in refusal skills the value of current anti-tobacco curricula needs to be assessed17 Even if the curriculum being used does have regular refusal skills training the teachers may not be implementing the program appropriately18
CHKS Report 2008-09 5 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
over time as would be expected Theoretically this should be accompanied by a reduction in overall smoking rates
ADULT SMOKING Question D16 About how many adults you know smoke cigarettes
In Table D8 youth estimates of the proportion of adults they know who smoke at least once a month are presented (none some many most or all) Adult behavior provides a model for youth The results for this item can be used in parent education efforts to demonstrate how studentsrsquo perception of adult use might influence their decisions to use or not to use (If the supplementary Module C was also administered these findings can be compared with their estimates of adult use of marijuana)
ACCESS TO CIGARETTES
Question D5 If you smoked cigarettes during the past 30 days how did you usually get them
The Core module asks students to identify how easy it is to obtain cigarettes (see Table A47) To shed further light on cigarette availability Table D9 provides data on where students obtain cigarettes
Recent laws have attempted to make it more difficult for underage youth to obtain cigarettes Store employees are instructed to ask people for proof of age when they attempt to purchase cigarettes Many stores keep their cigarette displays locked so adolescents cannot steal cigarettes Cigarette vending machines have been removed from many places where adolescents could access them However these policies are effective only if enforced9 It is important to determine whether these policies have indeed made it more difficult for adolescents to obtain cigarettes from retail sources
What percent of students reported purchasing cigarettes from retail sources and were not asked to show proof of age The 2001 YRBS reported that 19 of the high school students who had smoked in the past month had purchased cigarettes at a store or gas station in the past month Among the underage students who had purchased cigarettes at a store or gas station 67 reported that they were not asked to show proof of age10 If students are getting cigarettes from retail sources policies restricting youth access are not being enforced
What percent of students reported stealing cigarettes from people or stores What percent of students reported getting their cigarettes from friends or family members If they are getting cigarettes from social sources older relatives and friends may need to be educated about the importance of not giving cigarettes to minors Now that it is more difficult for adolescents to obtain cigarettes from retail sources some researchers have speculated that they may rely more heavily on social sources (friends and relatives) or illegal channels to obtain their cigarettes
CHKS Report 2008-09 3 Tobacco Module D
SMOKING CESSATION
Question D7 If you now smoke cigarettes would you like to quit smoking Question D8 How many times have you tried to quit smoking cigarettes Question D9-11 If you used tobacco during the past 12 months did you do any of the following things at school to get help to quit using hellipgo to a special group or class helliptalk to an adult at your school about how to quit helliptalk to a peer helper about how to quit
The CHKS asks youth five cessation-related questions whether they desired to quit the frequency of cessation attempts and whether they ever sought help to quit at the school from an adult or peer helper or from a special group or class Providing encouragement and support for youth cessation efforts is extremely important because the process of quitting smoking is extremely difficult11 People who try to quit smoking often have intense negative physical and psychological reactions that make them extremely likely to relapse They typically attempt to quit smoking several times before they quit successfully12 In this process they typically progress through stages of change of which five have been identified
bull not wanting to quit
bull contemplating it
bull taking action
bull a risk relapse stage and
bull finally a maintenance stage in which the smoker has abstained from smoking for a long period of time such as six months and has a high probability of success
This Transtheoretical Model of Change (TMC) also referred to as the Stages of Change Theory maintains that the way to help people quit smoking is to develop programs that address the participantrsquos readiness to change Unlike some stage models it recognizes that subjects can move back and forth between stages or recycle several times through the stages Unfortunately a major controlled scientific trial failed to support the utility of the Stages of Change Theory for increasing effectiveness of tobacco control efforts targeted to British school children13 However that is not to say that programs using this approach should not be included in your districtrsquos cessation efforts
Table D10 provides the proportion of students who have a desire to quit If only a few smokers express a desire to quit then efforts may need to be focused on demonstrating why they should stop If a large proportion wish to quit it may be a good idea to establish a school-based smoking cessation clinic or class or at least a referral process for referral to a community-based program This is particularly important if a high proportion indicate a desire to quit but relatively few have ever tried as indicated in Table D11 Students may be more likely to quit successfully if they have support from other students who wish to quit school staff and trained health educators
Table D11 reports the frequency that smokers have attempted to quit smoking The CSS has shown consistently that just under half of the 9th- and 11th-grade smokers (40 and 48 respectively) try to stop the habit at least once This is a higher cessation-attempt rate than found for illicit drugs and over twice as high as found for alcohol
Table D12 reports the proportion of students who ever went to a special group or class at school or who ever talked with an adult or peer helper at school about quitting If these services are available but students are not using them greater outreach efforts are clearly needed Consideration should be given to assessing the adequacy of the school TUPE program in promoting the benefits of quitting This is particularly important if students express a high desire to quit andor frequency of quit attempts
CHKS Report 2008-09 4 Tobacco Module D
PREVENTION PROGRAM EXPOSURE
Module D has been designed especially with the needs of TUPE program development in mind Table D7 reports student agreement with eight statements about smoking and its effects that are typically covered by prevention curricula Tables D13 through D15 below help assess exposure to any tobacco lessons and to refusal skills training one of the most common tobacco education strategies
EXPOSURE TO ANY LESSONS Question D13 During the past 12 months did you do any of these things at school helliphave lessons about tobacco and its effects on the body
The CHKS asks respondents about whether they had any lessons in school about tobacco and its effects on the body in the past year The results are reported in Table D13 If a high proportion report ldquoyesrdquo you might compare the curriculum content with the strategies assessed by other items in the surveymdash such as adverse consequences refusal skills and normative educationmdashto determine how well the intended messages have been learned If a high proportion of students say ldquonordquo or ldquodonrsquot knowrdquo the adequacy of current prevention efforts needs to be examined
REFUSAL SKILLS TRAINING (SELF-EFFICACY) Question D12 How hard would it be for you to refuse or say ldquonordquo to a friend who offered you a cigarette to smoke Question D14 During the past 12 months did you do any of these things at school hellippractice different ways to refuse or say ldquonordquo to tobacco offers
In Tables D14 and D15 students report on whether they had any practice saying ldquonordquo to tobacco offers in the past year and on their ability to refuse a friendrsquos offer of a cigarette to smoke Confidence in onersquos ability to perform an action successfully is called self-efficacy People tend to perform the actions that they think they can perform well and they tend to avoid actions that they think they are unable to perform14 Some students are not confident that they could successfully resist a cigarette offer from a peer they may not even try to say ldquonordquo
It is not easy for students to tell their friends that they do not want to engage in behavior that their friends think is acceptable15 Prevention research has shown that it is not enough to just tell youth to ldquojust say nordquo Self-efficacy develops through successful performance of the behavior They need to engage in role-playing and practice These skills must be reinforced with regular booster sessions and practiced each year until students feel confident in their ability to refuse tobacco Students who have practiced saying ldquonordquo and have been successful will have increased confidence and be more likely to say ldquonordquo in the future
Most tobacco prevention curricula that have shown effectiveness incorporate refusal skills training16
Typically students do role-plays in which one student offers a cigarette and another student practices saying ldquonordquo If the student says ldquonordquo assertively and firmly compliment the student If the student seems uncertain brainstorm ways that the student can say ldquonordquo more assertively without being bullied ridiculed or pressured into trying the cigarette Of course students will say ldquonordquo to a cigarette offer only if they truly do not want to smoke Therefore it is not enough to teach students how to say ldquonordquo Students must be convinced that smoking is not attractive or cool
If respondents report that they havenrsquot received any resistance training in the past year or students have had training but report little confidence in refusal skills the value of current anti-tobacco curricula needs to be assessed17 Even if the curriculum being used does have regular refusal skills training the teachers may not be implementing the program appropriately18
CHKS Report 2008-09 5 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
SMOKING CESSATION
Question D7 If you now smoke cigarettes would you like to quit smoking Question D8 How many times have you tried to quit smoking cigarettes Question D9-11 If you used tobacco during the past 12 months did you do any of the following things at school to get help to quit using hellipgo to a special group or class helliptalk to an adult at your school about how to quit helliptalk to a peer helper about how to quit
The CHKS asks youth five cessation-related questions whether they desired to quit the frequency of cessation attempts and whether they ever sought help to quit at the school from an adult or peer helper or from a special group or class Providing encouragement and support for youth cessation efforts is extremely important because the process of quitting smoking is extremely difficult11 People who try to quit smoking often have intense negative physical and psychological reactions that make them extremely likely to relapse They typically attempt to quit smoking several times before they quit successfully12 In this process they typically progress through stages of change of which five have been identified
bull not wanting to quit
bull contemplating it
bull taking action
bull a risk relapse stage and
bull finally a maintenance stage in which the smoker has abstained from smoking for a long period of time such as six months and has a high probability of success
This Transtheoretical Model of Change (TMC) also referred to as the Stages of Change Theory maintains that the way to help people quit smoking is to develop programs that address the participantrsquos readiness to change Unlike some stage models it recognizes that subjects can move back and forth between stages or recycle several times through the stages Unfortunately a major controlled scientific trial failed to support the utility of the Stages of Change Theory for increasing effectiveness of tobacco control efforts targeted to British school children13 However that is not to say that programs using this approach should not be included in your districtrsquos cessation efforts
Table D10 provides the proportion of students who have a desire to quit If only a few smokers express a desire to quit then efforts may need to be focused on demonstrating why they should stop If a large proportion wish to quit it may be a good idea to establish a school-based smoking cessation clinic or class or at least a referral process for referral to a community-based program This is particularly important if a high proportion indicate a desire to quit but relatively few have ever tried as indicated in Table D11 Students may be more likely to quit successfully if they have support from other students who wish to quit school staff and trained health educators
Table D11 reports the frequency that smokers have attempted to quit smoking The CSS has shown consistently that just under half of the 9th- and 11th-grade smokers (40 and 48 respectively) try to stop the habit at least once This is a higher cessation-attempt rate than found for illicit drugs and over twice as high as found for alcohol
Table D12 reports the proportion of students who ever went to a special group or class at school or who ever talked with an adult or peer helper at school about quitting If these services are available but students are not using them greater outreach efforts are clearly needed Consideration should be given to assessing the adequacy of the school TUPE program in promoting the benefits of quitting This is particularly important if students express a high desire to quit andor frequency of quit attempts
CHKS Report 2008-09 4 Tobacco Module D
PREVENTION PROGRAM EXPOSURE
Module D has been designed especially with the needs of TUPE program development in mind Table D7 reports student agreement with eight statements about smoking and its effects that are typically covered by prevention curricula Tables D13 through D15 below help assess exposure to any tobacco lessons and to refusal skills training one of the most common tobacco education strategies
EXPOSURE TO ANY LESSONS Question D13 During the past 12 months did you do any of these things at school helliphave lessons about tobacco and its effects on the body
The CHKS asks respondents about whether they had any lessons in school about tobacco and its effects on the body in the past year The results are reported in Table D13 If a high proportion report ldquoyesrdquo you might compare the curriculum content with the strategies assessed by other items in the surveymdash such as adverse consequences refusal skills and normative educationmdashto determine how well the intended messages have been learned If a high proportion of students say ldquonordquo or ldquodonrsquot knowrdquo the adequacy of current prevention efforts needs to be examined
REFUSAL SKILLS TRAINING (SELF-EFFICACY) Question D12 How hard would it be for you to refuse or say ldquonordquo to a friend who offered you a cigarette to smoke Question D14 During the past 12 months did you do any of these things at school hellippractice different ways to refuse or say ldquonordquo to tobacco offers
In Tables D14 and D15 students report on whether they had any practice saying ldquonordquo to tobacco offers in the past year and on their ability to refuse a friendrsquos offer of a cigarette to smoke Confidence in onersquos ability to perform an action successfully is called self-efficacy People tend to perform the actions that they think they can perform well and they tend to avoid actions that they think they are unable to perform14 Some students are not confident that they could successfully resist a cigarette offer from a peer they may not even try to say ldquonordquo
It is not easy for students to tell their friends that they do not want to engage in behavior that their friends think is acceptable15 Prevention research has shown that it is not enough to just tell youth to ldquojust say nordquo Self-efficacy develops through successful performance of the behavior They need to engage in role-playing and practice These skills must be reinforced with regular booster sessions and practiced each year until students feel confident in their ability to refuse tobacco Students who have practiced saying ldquonordquo and have been successful will have increased confidence and be more likely to say ldquonordquo in the future
Most tobacco prevention curricula that have shown effectiveness incorporate refusal skills training16
Typically students do role-plays in which one student offers a cigarette and another student practices saying ldquonordquo If the student says ldquonordquo assertively and firmly compliment the student If the student seems uncertain brainstorm ways that the student can say ldquonordquo more assertively without being bullied ridiculed or pressured into trying the cigarette Of course students will say ldquonordquo to a cigarette offer only if they truly do not want to smoke Therefore it is not enough to teach students how to say ldquonordquo Students must be convinced that smoking is not attractive or cool
If respondents report that they havenrsquot received any resistance training in the past year or students have had training but report little confidence in refusal skills the value of current anti-tobacco curricula needs to be assessed17 Even if the curriculum being used does have regular refusal skills training the teachers may not be implementing the program appropriately18
CHKS Report 2008-09 5 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
PREVENTION PROGRAM EXPOSURE
Module D has been designed especially with the needs of TUPE program development in mind Table D7 reports student agreement with eight statements about smoking and its effects that are typically covered by prevention curricula Tables D13 through D15 below help assess exposure to any tobacco lessons and to refusal skills training one of the most common tobacco education strategies
EXPOSURE TO ANY LESSONS Question D13 During the past 12 months did you do any of these things at school helliphave lessons about tobacco and its effects on the body
The CHKS asks respondents about whether they had any lessons in school about tobacco and its effects on the body in the past year The results are reported in Table D13 If a high proportion report ldquoyesrdquo you might compare the curriculum content with the strategies assessed by other items in the surveymdash such as adverse consequences refusal skills and normative educationmdashto determine how well the intended messages have been learned If a high proportion of students say ldquonordquo or ldquodonrsquot knowrdquo the adequacy of current prevention efforts needs to be examined
REFUSAL SKILLS TRAINING (SELF-EFFICACY) Question D12 How hard would it be for you to refuse or say ldquonordquo to a friend who offered you a cigarette to smoke Question D14 During the past 12 months did you do any of these things at school hellippractice different ways to refuse or say ldquonordquo to tobacco offers
In Tables D14 and D15 students report on whether they had any practice saying ldquonordquo to tobacco offers in the past year and on their ability to refuse a friendrsquos offer of a cigarette to smoke Confidence in onersquos ability to perform an action successfully is called self-efficacy People tend to perform the actions that they think they can perform well and they tend to avoid actions that they think they are unable to perform14 Some students are not confident that they could successfully resist a cigarette offer from a peer they may not even try to say ldquonordquo
It is not easy for students to tell their friends that they do not want to engage in behavior that their friends think is acceptable15 Prevention research has shown that it is not enough to just tell youth to ldquojust say nordquo Self-efficacy develops through successful performance of the behavior They need to engage in role-playing and practice These skills must be reinforced with regular booster sessions and practiced each year until students feel confident in their ability to refuse tobacco Students who have practiced saying ldquonordquo and have been successful will have increased confidence and be more likely to say ldquonordquo in the future
Most tobacco prevention curricula that have shown effectiveness incorporate refusal skills training16
Typically students do role-plays in which one student offers a cigarette and another student practices saying ldquonordquo If the student says ldquonordquo assertively and firmly compliment the student If the student seems uncertain brainstorm ways that the student can say ldquonordquo more assertively without being bullied ridiculed or pressured into trying the cigarette Of course students will say ldquonordquo to a cigarette offer only if they truly do not want to smoke Therefore it is not enough to teach students how to say ldquonordquo Students must be convinced that smoking is not attractive or cool
If respondents report that they havenrsquot received any resistance training in the past year or students have had training but report little confidence in refusal skills the value of current anti-tobacco curricula needs to be assessed17 Even if the curriculum being used does have regular refusal skills training the teachers may not be implementing the program appropriately18
CHKS Report 2008-09 5 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
You might want to further analyze your results to determine if the percentage of students who feel that they would be unable to say ldquonordquo differs by grade level gender or ethnicity Some researchers have speculated that adolescents from certain cultural backgrounds (such as Asian Americans or HispanicLatinos) may have difficulty saying ldquonordquo because their cultural norms and values emphasize harmonious relationships with other people
Research also suggests that the assertiveness skills and negotiation skills used to refuse cigarette offers are also useful in helping adolescents to avoid other undesirable behaviors such as drug use unsafe sex fighting and gangs19 Thus if students report lacking these skills it may be a good idea to implement a school-wide generic program to teach assertiveness skills conflict resolution skills and negotiation skills
Endnotes
1 Choi et al (1997) 2 Centers for Disease Control (1997) 3 Wald N J amp Watt H C (1997) 4 For example Kaplan et al (2001) 5 Hurd et al (1980) 6 Independent Evaluation Consortium (1998) 7 Hansen W B amp Graham J W (1991) 8 Flay Petraitis amp Hu (1999) 9 Jones et al (2002) 10 Grunbaum et al (2002) 11 Fiore et al (1990) 12 Pallonen et al (1998) 13 Aveyard et al (1999) 14 Bandura A (1986) 15 Friedman Lichtenstein amp Biglan (1985) 16 Ellickson amp Hays (1990) 17 Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction 18 Botvin et al (1990) 19 Charlton Minagawa amp While (1999)
CHKS Report 2008-09 6 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
REFERENCES
Aveyard P Cheng K K Almond J Sherratt E Lancashire R Lawrence T Griffin C amp Evans O (1999) Cluster randomised controlled trial of expert system based on the transtheoretical (stages of change) model for smoking prevention and cessation in schools British Medical Journal 319(7215) 948-53
Bandura A (1986) Social Foundations of thought and action A social cognitive theory Englewood Cliffs NJ Prentice Hall
Botvin G J Baker E Goldberg C J Dusenbury L amp Botvin E M (1992) Correlates and predictors of smoking among black adolescents Addictive Behaviors 17 97-103
Botvin G J Botvin E M Baker E Dusenbury L amp Goldberg C J (1992) The false consensus effect predicting adolescents tobacco use from normative expectations Psychological Reports 70(1) 171-8
Botvin G J Baker E Filazzola A amp Botvin E (1990) A cognitive-behavioral approach to substance abuse prevention One-year follow-up Addictive Behaviors 15(1) 47-63
Centers for Disease Control (1994) Guidelines for school health programs to prevent tobacco use and addiction Morbidity and Mortality Weekly Report 43(RR-2) 1-18
Centers for Disease Control (1997) Cigar smoking among teenagersmdashUnited States Massachusetts and New York 1996 Morbidity Mortality Weekly Report 46(20) 433-440
Centers for Disease Control (2000) Youth tobacco surveillancemdashUnited States 1998-1999 Morbidity Mortality Weekly Report 49(SS10) 1-94
Choi W S Pierce J P Gilpin E A Farkas A J amp Berry C C (1997) Which aolescent experiments progress to established smoking in the United States American Journal of Preventive Medicine 13 385-391
Charlton A Minagawa K E amp While D (1999) Saying no to cigarettes A reappraisal of adolescent refusal skills Journal of Adolescence 22(5) 695-707
Ellickson P L amp Hays R D (1990) Beliefs about resistance self-efficacy and drug prevalence Do they really affect drug use International Journal of Addiction 25(11A) 1353-78
Epstein J A Griffin K W amp Botvin G J (2000) Competence skills help deter smoking among inner city adolescents Tobacco Control 9 33-39
Fiore M C Novotny T E Pierce J P Giovino G A Hatziandreu E J Newcomb P A Surawicz T S amp Davis R M (1990) Methods used to quit smoking in the United States Do cessation programs help Journal of the American Medical Association 263(20) 2760-5
Flay B R Petraitis J amp Hu F B (1999) Psychosocial risk and protective factors for adolescent tobacco use Nicotine Tobacco Research 1 (Suppl 1) S59-65
Friedman L S Lichtenstein E amp Biglan A (1985) Smoking onset among teens An empirical analysis of initial situations Addictive Behaviors 10 1-13
Grunbaum J A Kann L Kinchen S A Williams B Ross J G Lowry R amp Kolbe L (2002) Youth Risk Behavior Surveillance United States Morbidity and Morality Weekly Report 51(SS04) I-64
Hansen W B amp Graham J W (1991) Preventing alcohol marijuana and cigarette use among adolescents Peer pressure resistance training versus establishing conservative norms Preventive Medicine 20(3) 414-30
Hurd P D Johnson C A Pechacek T Bast L P Jacobs D R amp Luepker R V (1980) Prevention of cigarette smoking in seventh grade students Journal of Behavioral Medicine 3(1) 15-28
Independent Evaluation Consortium (1998) Final Report of the Independent Evaluation of the California Tobacco Control Prevention and Education Program Wave 1 Data 1996-1997 Rockville MD The Gallup Organization
CHKS Report 2008-09 7 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
Jones S E Sharp D J Husten C G amp Crossett L S (2002) Cigarette acquisition and proof of age among US high school students who smoke Tobacco Control 11(1) 20-5
Kaplan C P Napoles-Springer A Stewart S L amp Perez-Stable E J (2001) Smoking acquisition among adolescents and young Latinas the role of socioenvironmental and personal factors Addictive Behaviors 26(4) 531-50
Pallonen U E Prochaska J O Velicer W F Prokhorov A V amp Smith N F (1998) Stages of acquisition and cessation for adolescent smoking An empirical integration Addictive Behaviors 23 303-24
Wald N J amp Watt H C (1997) Prospective study of effect of switching from cigarettes to pipes or cigars on mortality from three smoking related diseases British Medical Journal 314(7098) 1860-3
CHKS Report 2008-09 8 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
TABLES
TOBACCO MODULE D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashMODULE D
HighMiddle School Item Variable Report Table
D1 Ever smoked daily D2 D2 Ever smoke to control weight D5 D3 Number of cigarettes smoked per day past 30 days D1 D4 Smoked 100 cigarettes lifetime D3 D5 Sources for obtaining cigarettes D9 D6 Current cigar smoking past 30 days D4 D7 Current desire to quit smoking cigarettes D10 D8 Lifetime frequency of smoking cessation attempts D11 D9 Go to special group to quit past 12 months D12 D10 Talk to adult about how to quit past 12 months D12 D11 Talk to peer helper about how to quit past 12 months D12 D12 Perceived ability to refuse friends offer of cigarettes D15 D13 Tobacco education in school past 12 months D13 D14 Refusal skills training in school past 12 months D14 D15 Likelihood of smoking in the next year D6 D16 Estimated prevalence of adult cigarette smoking monthly D8 D17 Attitudes toward smoking grown-up D7 D18 Attitudes toward smoking teeth yellow D7 D19 Attitudes toward smoking cool D7 D20 Attitudes toward smoking smell bad D7 D21 Attitudes toward smoking make friends D7 D22 Attitudes toward smoking bad for health D7 D23 Attitudes toward smoking helps relax D7 D24 Attitudes toward smoking control weight D7
CHKS Report 2008-09 10 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
INDEX OF ITEM AND TABLE NUMBERSmdashCORE MODULE A
High Middle School School Report Item Item Variable Table
A21-23 A21-23 Ever tried smoking a cigarette or using smokeless tobacco A41 A43-44 A38-39 Any and daily use of cigarettes and smokeless tobacco A43
past 30 days A56 A47 Current smoking on school property past 30 days A44 A69 A59 Peer disapproval of using cigarettes A45 A61 A51 Perceived harm of frequent cigarette smoking A46 A64 A54 Perceived difficulty of obtaining cigarettes A47 A67 A57 Estimated prevalence of peer cigarette smoking at least once a A48
month
CHKS Report 2008-09 11 Tobacco Module D
